Difference between revisions of "Issues & Immunizations 4.1"

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{{Languages|Issues & Immunizations 4.1}}
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<<  [[New Encounters & Coding 4.1|New Encounters & Coding]]
<<  [[New Encounters & Coding 4.1|New Encounters & Coding]]


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This is especially useful with medical problems, where the user may want to quickly determine which encounters treated a particular problem, or which problems were treated by a particular encounter.  
This is especially useful with medical problems, where the user may want to quickly determine which encounters treated a particular problem, or which problems were treated by a particular encounter.  


The Issues list can be found on the right-hand side of the Patient Summary page. 


[[File:66 (Patient Info with Prescription Update).jpg|800px]]


[[File:082-issues with medication.png|800px]]


The Issues list can be found on the right-hand side of the Patient Summary page.


You can see that the prescription added earlier has been listed in the Medications section.  Clicking 'Edit' next to one of these sections will present you with this patient's issues list for that category.  Click 'Add' to add a new medical issue you want to kept track of for this patient.


[[File:67 (Medical Problems on info page).jpg|800px]]


[[File:083-medical problems list.png|800px]]


You can see that the prescription added earlier has been listed in the Medications section.  Clicking 'Edit' next to one of these sections will present you with a complete list of all issues for this patient.  Click 'Add Issue' to add a new medical issue you want to kept track of for this patient.


This pops up the Add New Issue dialog box. 


[[File:68 (Medical Problems main Page).jpg|800px]]


[[File:084-select occurence.png]]


This pops up the 'Add Issue' dialog box.


 
For each issue type there is a list of commonly selected titles which are customizable for your clinic's specific needs.  If the desired title is not included, it can be typed into the text box below the list.  
[[File:075.png]]
 
 
The default issue type is set to 'Problem'.  For each issue type there is a list of commonly selected titles which are customizable for your clinic's specific needs.  If the desired title is not included, it can be typed into the text box below the list.  


Enter the appropriate beginning and end dates, and select the 'Occurrence' from the drop-down list provided.
Enter the appropriate beginning and end dates, and select the 'Occurrence' from the drop-down list provided.
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[[File:076.png]]  
[[File:085-diagnosis code search.png]]




Complete the remainder of the form as necessary and click 'Save'.   
Complete the remainder of the form as necessary and click 'Save'.   
Additional issues are entered in the same manner; click 'Back' to return to the Patient Summary page and click 'Add' next to the appropriate issue type, or click 'Issues' at the top of the page to see a complete list of all issues for this patient.  Notice that the 'Add New Issue' dialog also uses the OpenEMR date selection tool described earlier. 




[[File:077.png]]  
[[File:087-add allergy.png]]




Additional issues are entered in the same manner; clicking 'Add Issue' and selecting the appropriate type, such as 'Allergy'Notice that the 'Add New Issue' dialog also uses the OpenEMR date selection tool described earlier.
Once the new issues have been added successfully you should see an updated list of all the issues that have been entered for this patientYou may click on an issue in the list at any time to edit it.




[[File:078.png]]  
[[File:088-issues list.png|800px]]




Once the new issues have been added successfully you should see an updated list of all the issues that have been entered for this patient.  You may click on an issue in the list at any time to edit it.


===Associating Issues with Encounters===


[[File:72 (Issue List).jpg|800px]]
The far right column in the Issues list represents the number of encounters associated with a given issue.  Click on the '0' next to a newly added issue to bring up the Issues & Encounters dialog.




===Associating Issues with Encounters===
[[File:089-view related encounter.png|800px]]


The far right column in the Issues list represents the number of encounters associated with a given issue.  Click on the '0' next to a newly added issue to bring up the 'Issues & Encounters' dialog.


This dialog contains a list of all the issues and encounters associated with this patient.  It is used to set (and view) the relationships between issues and encounters.  Note that the issue that was just clicked on has been highlighted. 


[[File:080.png]]


[[File:090-issues and encounters.png]]


This dialog contains a list of all the issues and encounters associated with this patient.  It is used to set (and view) the relationships between issues and encounters.  Note that the issue that was just clicked on has been highlighted. 


Select the appropriate encounter from the list on the right to highlight it.  Clicking 'Save' now links the selected issue to the selected encounter.
Select the appropriate encounter from the list on the right to highlight it.  Clicking 'Save' now links the selected issue to the selected encounter.




[[File:081.png]]  
[[File:091-associate with encounter.png]]




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[[File:082.png]]  
[[File:092-updated issues list.png|800px]]
 




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[[File:73 (Immunizations Page).jpg|800px]]
[[File:093-immunization form.png|800px]]
 
 
Click inside the 'Immunization (CVX Code) field & select the correct immunization code using the search dialog provided. 
 
 
[[File:094-CVX code search.png]]
 
 
Enter any data you may have, including the date of the shot, and the name of the provider who administered it.  Click 'Save Immunization'. The newly added immunization now appears in the list at the bottom of the screen.
 
 
[[File:095-immunization list.png|800px]]
 
 
Return to the Summary page via the navigation menu on the left.  Notice that the right side of the Patient Summary page now shows an updated list of all active issues, immunizations and prescriptions.
 


[[File:096-full issues list.png|800px]]


Select the type of immunization from the drop-down list provided, and enter any data you may have, including the date of the shot, and the name of the provider who administered it. 
===Sending HL7 file to Immunization Registry===


Click 'Save Immunization'. The newly added immunization now appears in the list at the bottom of the screen.
To send a file to an Immunization Registry in your state. First, contact the state and get the information on how to connect with them to transmit the information. Go to the address book and add the registry information under immunizations.


[[File: Immunization registry.png|600px]]


[[File:74 (Immunizations update).jpg|800px]]
Then go to Reports > Client > Immunization Registry




Return to the Summary page via the navigation menu on the left.  Notice that the lower left portion of the patient summary now shows an updated list of all active issues, immunizations and prescriptions.
[[File: Immunization registry menu.png|500px]]




[[File:75 (Summary with Immunization update).jpg|800px]]
Run the report for the time period that you would like to send data from. Once the report is ready. There will be a button to Get HL7




>>  [[Patient Notes & Transactions 4.1|Patient Notes & Transactions]]
>>  [[Patient Notes & Transactions 4.1|Patient Notes & Transactions]]
[[Category:User Guide 4.2.0]][[Category:User Guide 4.1.0]][[Category:User Guide]]

Latest revision as of 08:29, 2 December 2023

Available languages
English


<< New Encounters & Coding


Issues & Immunizations

Adding Issues

An "issue" is a medical problem, allergy, medication, surgery or dental issue. These issues are related in that they can all be associated with multiple encounters.

This is especially useful with medical problems, where the user may want to quickly determine which encounters treated a particular problem, or which problems were treated by a particular encounter.

The Issues list can be found on the right-hand side of the Patient Summary page.


082-issues with medication.png


You can see that the prescription added earlier has been listed in the Medications section. Clicking 'Edit' next to one of these sections will present you with this patient's issues list for that category. Click 'Add' to add a new medical issue you want to kept track of for this patient.


083-medical problems list.png


This pops up the Add New Issue dialog box.


084-select occurence.png


For each issue type there is a list of commonly selected titles which are customizable for your clinic's specific needs. If the desired title is not included, it can be typed into the text box below the list.

Enter the appropriate beginning and end dates, and select the 'Occurrence' from the drop-down list provided. Clicking in the 'Diagnosis' field will present a search dialog for locating the correct ICD9 code for this issue. Enter the appropriate search term and click 'Search' to bring up a list of possible ICD9 codes. Selecting the desired code will close the search window and enter the selected code in the text field.


085-diagnosis code search.png


Complete the remainder of the form as necessary and click 'Save'.

Additional issues are entered in the same manner; click 'Back' to return to the Patient Summary page and click 'Add' next to the appropriate issue type, or click 'Issues' at the top of the page to see a complete list of all issues for this patient. Notice that the 'Add New Issue' dialog also uses the OpenEMR date selection tool described earlier.


087-add allergy.png


Once the new issues have been added successfully you should see an updated list of all the issues that have been entered for this patient. You may click on an issue in the list at any time to edit it.


088-issues list.png


Associating Issues with Encounters

The far right column in the Issues list represents the number of encounters associated with a given issue. Click on the '0' next to a newly added issue to bring up the Issues & Encounters dialog.


089-view related encounter.png


This dialog contains a list of all the issues and encounters associated with this patient. It is used to set (and view) the relationships between issues and encounters. Note that the issue that was just clicked on has been highlighted.


090-issues and encounters.png


Select the appropriate encounter from the list on the right to highlight it. Clicking 'Save' now links the selected issue to the selected encounter.


091-associate with encounter.png


Continue associating issues with encounters as necessary. Refreshing the Issues list shows the current information for all issues.


092-updated issues list.png


Immunizations

Click 'Back' to return to the Patient Summary page. Now click 'Edit' next to the Immunizations section. This page contains a form for entering information on any immunizations the patient has received.


093-immunization form.png


Click inside the 'Immunization (CVX Code) field & select the correct immunization code using the search dialog provided.


094-CVX code search.png


Enter any data you may have, including the date of the shot, and the name of the provider who administered it. Click 'Save Immunization'. The newly added immunization now appears in the list at the bottom of the screen.


095-immunization list.png


Return to the Summary page via the navigation menu on the left. Notice that the right side of the Patient Summary page now shows an updated list of all active issues, immunizations and prescriptions.


096-full issues list.png

Sending HL7 file to Immunization Registry

To send a file to an Immunization Registry in your state. First, contact the state and get the information on how to connect with them to transmit the information. Go to the address book and add the registry information under immunizations.

Immunization registry.png


Then go to Reports > Client > Immunization Registry


Immunization registry menu.png


Run the report for the time period that you would like to send data from. Once the report is ready. There will be a button to Get HL7


>> Patient Notes & Transactions